Online Guest Referral Form

Please be advised that referrals must be prepared by a member of the health team and not by the guest.

Fax and Email are not monitored overnight (10:00pm – 8:00 am). If referrals are urgent, please call to ensure the referral has been received.

    Guest Information

    Date of Referral

    Date Room is Needed

    Guest Name (Required)

    Guest Address

    City

    Postal Code

    Patient/Family Phone number (required)

    Patient/Family Cell number

    Number of people requiring accommodation (Select One)

    Name(s) of additional guests (Separate by commas)

    Patient Information

    Patient name

    Ward patient is being admitted to

    Estimated length of stay

    Referral Made By

    Name (required)

    Contact number (required)


    Extension

    Email (required)

    Profession

    Hospital

    Notes (please indicate priority, any special guest requirements or circumstances, etc)

    Consent to share information (Required)

    YES - I authorize to provide the Mark Preece Family House with the above information and to confirm that the above mentioned patient is being admitted to the hospital mentioned above.

    • Cost to stay is $60 per room per night (Visa, MC, debit, cash or cheque accepted)

    • Free parking is provided on location